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PFRVFf�-'CTTifA�,_TTOODA�_.'_Y�( CONSENT TO TATTOO PROCEDURE Name: Date: D.O.B. &Age: ID/License No.: Phone: Address: Do you have any allergies to any antibiotics? Do you have a history of medication use,or are currently using medication including prescribed antibiotics prior to a surgical or dental procedure?Please list: Do you have HIV,Hepatitis B,Hepatitis C,or other risk factors for bloodborne pathogens? I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows: ❑ I do not require antibiotics before surgery or dental procedures. ❑ If I have any condition that might affect the healing of this tattoo, I will advise my tattooer. ❑ I am not pregnant,nursing,or under the influence of alcohol or drugs. ❑ I do not have medical or skin conditions such as but not limited to:acne,scarring(keloid),eczema,psoriasis,freckles,moles,sunburn or herpes in the area to be tattooed that may interfere with said tattoo.If I have any type of infection or rash anywhere on my body, I will advise my tattooer. ❑ If I have any history of hemophelia or other bleeding disorder,diabetes or any heart conditions such as cardiac valve disease I will let the artist know. ❑ I have advised the tattooer of any allergies to metals, latex gloves,soaps and medications. I acknowledge it is not reasonably possible for the tattooer or other employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes involved in the tattoo and further acknowledge that such a reaction is possible. I agree to accept the risk that such a reaction is possible. ❑ I accept aftercare instructions and I agree to follow them while my tattoo is healing.Signs of infection include but are not limited to:redness, swelling,tenderness,red streaks towards the heart,elevated body temperature,purulent drainage from procedure site. If I experience signs/ symptoms I will seek medical attention. I agree that any touch-up work needed,due to my own negligence,will be done at my own expense. ❑ I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark,the colors will not appear as bright as they do on fairer skin. ❑ I understand that if I have any skin treatments,laser hair removal,plastic surgery or other skin altering procedures,it may result in adverse changes to my tattoo. ❑ I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo.To my knowledge, I do not have a physical,mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo. ❑ I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform this tattoo procedure. Tattoo inks, dyes and pigments have not been approved by the federal food and drug administration and the health consequences of using these products are unknown. After the tattoo procedure you can expect minor soreness,swelling for a short period of time followed by your tattoo peeling(like a sunburn does)as part of the healing process. Signature: Date: Tattooer: Tattoo: NEEDLE BATCH: DATE: TUBE BATCH: DATE: